Anti-TNF Coverage Determination Form Cigna …

1 Anti-TNF Coverage Determination (FOR PROVIDER USE ONLY) Customer ID:Customer DOB:Customer Address:Phone (Home):Phone (Cell):NPI Number:Provider Name:Provider Address:Drug Name:Dosage:Frequency:Quantity:Refills: New Medication ContinuationProvide Start Date---------> Ankylosing Spondylitis Plaque Psoriasis Crohn's Disease (Fistulizing, Ulcerative Colitis) Psoriatic Arthritis Hidradenitis Suppurativa Rheumatoid Arthritis Juvenile Rheumatoid Arthritis Uveitis Other _____SELECT DIAGNOSISMEMBER INFORMATION REQUIRED (Please Write Legibly)Customer Name:PROVIDER INFORMATION REQUIRED (Please Write Legibly)License Number:DEA Number: Do Not Substitute-Dispense As WrittenProvider Specialty:DRUG & PRESCRIPTION INFORMATION REQUIRED (Please Write Legibly)Provider Phone:Please check whether this is a new medication or therapy continuationProvider Fax:Office Contact Name:If you have checked "Continuation", AntiTNF_FormINT_17_59000 09152017 Page 1 of 3 Anti-TNF Coverage Determination (FOR PROVIDER USE ONLY) DosageFrequencyQuantity6-MercaptopurineA zathioprineCelebrexCorticosteroidsCyclop hosphamideEnbrel (prior authorization required)Gold compoundsHumira (prior authorization required)HydroxychloroquineImmunosuppres sivesLeflunomideMethotrexateOlsalazine (Dipentum)Oral Methoxsalen w/UVA lightPenicillamineRemicade (prior authorization required)SulfasalazineTopical anti -Psoriatic (list)Topical Corticosteriod (list)UVBUVB w/ Coal Tar or DithranolOther.

2 CLINICAL INFORMATION REQUIRED (Please Write Legibly)Treatment Outcome/Rationale for Non UseSELECT ALL FORMULARY AGENTS THAT THE CUSTOMER HAS TRIED/FAILED; PLEASE INCLUDE THE DOSAGE, FREQUENCY, QUANTITY, DURATION OF THERAPY (START AND END DATES), AND OUTCOME/RATIONALE FOR NON USE :Drug NameATTENTION: PLAN REQUIRES A TRIAL OF AT LEAST 2 FORMULARY ALTERNATIVES; FAILURE TO PROVIDE CLINICAL DOCUMENTATION SUPPORTING RATIONALE MAY RESULT IN THIS REQUEST BEING DENIED, OR AN ADDITIONAL OUTREACH TO OBTAIN MISSING CLINICAL DateStart DateAntiTNF_FormINT_17_59000 09152017 Page 2 of 3 Anti-TNF Coverage Determination (FOR PROVIDER USE ONLY) List NSAIDS tried:List weight in Kg: For Plaque Psoriasis List length of time (in months) present: List body surface area (BSA) % involvement: Does condition affect member's palms, soles, head, neck, or genitalia?

3 YES NOOther Questions:Is this request for an inpatient that is awaiting discharge? YES NOIf the customer is unable to meet the criteria required for the requested medication, please provide a clinical explanation as to why an exception should be made:Administration Site: Patient's home Home infusion Skilled nursing Physician's office Long Term CareDrug Supplied By: Pharmacy Physician's SupplyDate:Request for expedited review [24 hours]. By checking this box, I certify that applying the 72 hour standard review time frame may seriously jeopardize the life or health of the Customer or the Customer's ability to regain maximum function Other: _____ Other: _____All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc.

4 , Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna -HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna -HealthSpring depends on contract Signature:AntiTNF_FormINT_17_59000 09152017 Page 3 of 3